Forensic Science International 282 (2018) 94–100

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Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Ankle fracture — Correlation of Lauge-Hansen classification and patient

reported fracture mechanism
Andrzej Boszczyka,* , Marcin Fudalejb , Sławomir Kwapisza , Urszula Klimeka ,
Marta Maksymowicza , Bartłomiej Kordasiewicza , Stefan Rammeltc
a
Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Clinical Hospital, Konarskiego Str. 13, 05-400
Otwock, Poland
b
Forensic Medicine Department, Medical University of Warsaw, Wojciecha Oczki Str. 1, 00-001 Warsaw, Poland
c
University Center for Orthopaedics & Traumatology, University Hospital, Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: The genetic Lauge-Hansen classification is used for reconstruction of the mechanism of
Received 7 July 2017 ankle injury. In this study, we addressed the question of agreement between the mechanism of the
Received in revised form 12 November 2017 fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in
Accepted 13 November 2017
rotational ankle fractures.
Available online 21 November 2017
Material and methods: Radiographs of 78 patients with acute malleolar fractures were analyzed and
compared with fracture mechanisms reported by these patients.
Keywords:
Results: The patient reported mechanisms were in concordance with the mechanism deducted from the
Ankle fractures
Classification
X-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs
Trauma classified as pronation fractures while 76% of patients who recalled a supination trauma were also
X-ray radiographically classified as having sustained supination type fractures.
Accidents Conclusion: The Lauge-Hansen classification should be used with caution for determining the actual
mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of
cases. A substantial percentage of fractures appearing radiographically as supination type injuries may
have been actually produced by a pronation fracture mechanism.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction However, in more recent biomechanical studies the stages of this

Lower extremity injuries, including those at the ankle joint, are
common in medicolegal practice. From a medicolegal point of view
the ability to explain the circumstances and the mechanism of
injury may be crucial in terms of determining legal responsibility
for the incident [1–3].
The genetic Lauge-Hansen classification is considered to be one
of the basic sources of knowledge about fractures of the ankle and
thus widely used in forensic medicine for reconstruction of the
mechanism of injury [1–3].
The seminal work of Lauge-Hansen has been influencing our
understanding of ankle fracture mechanism for over seventy years
[4]. It provides a logical link between mechanism of both the bony
and ligamentous injury to the ankle and the resulting X-ray.
classification could not be reliably reproduced and there are
several clinical and cadaveric studies questioning consistency of
the proposed mechanisms [5–10].
In this study, we addressed the question of agreement between
the mechanism of the fracture as postulated by the Lauge-Hansen
classification and mechanism reported by the patient in rotational
ankle fractures.
The ability to deduct the mechanism of the injury from the
radiographic image of the fracture is of paramount importance in
medicolegal reasoning. To the best of our knowledge – and to our
surprise – the “real life” performance of the Lauge-Hansen
classification in this respect has not yet been tested. This study
aims at filling this void.
2. Patients and methods

* Corresponding author. 2.1. Patients

E-mail addresses: ortopeda@boszczyk.pl (A. Boszczyk), marcin_zms@wp.pl
(M. Fudalej), skwapisz@gmail.com (S. Kwapisz), urszula.u.klimek@gmail.com The study was performed at the Traumatology Department of a
(U. Klimek), maksymowicz.mm@gmail.com (M. Maksymowicz), bartekko@tlen.pl regional hospital. Consecutive patients admitted to the
(B. Kordasiewicz), Stefan.rammelt@uniklinikum-dresden.de (S. Rammelt).

https://doi.org/10.1016/j.forsciint.2017.11.023
0379-0738/© 2017 Elsevier B.V. All rights reserved.
 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100 95

Traumatology Department from November 2015 until February

2017 were screened for inclusion and exclusion criteria.
Inclusion criteria were ankle fractures (documented as AO/OTA
types 44A, 44B, or 44C) [11] requiring operative treatment in
patients aged at least 18 years and willing to participate in the
study. Patients were excluded if they were unable to provide the
circumstances of the injury, sustained the fracture while being
intoxicated or sustained a high-energy fracture (for example high
speed motor vehicle accident, fall from a height of more than
2 meters). Fractures of the tibial pilon (AO/OTA types 43) resulting
mainly from axial forces were also excluded.

2.2. Methods

Patients meeting the inclusion criteria were approached within

48 h after admission and after obtaining verbal consent asked for
details of their accident.
Patients were questioned by a surgeon from the team providing
their treatment. First, the patients were asked about the circum-
stances of the accident (i. e. fall, stumble, vehicle accident, direct
trauma, fall from a height, sports). This information was cross-
checked with the charts for consistency. Next, the patients were
asked to recall the fracture mechanism. At first, the patients were
asked to describe the mechanism in their own words. If the
patients experienced difficulty at this step, the investigator
presented supination and pronation with the investigator’s own
foot (in random order). If this was not sufficient, photographs
presenting these positions were presented to the patients. Due to
complexity of the movement we did not introduce a question
about internal/external rotation.
The ankle mortise and lateral radiographic views performed in
the emergency department were then analyzed. In patients with
fracture-dislocations, both the pre- and postreduction X-rays were
analyzed. A senior orthopedic surgeon and an orthopedic resident
independently classified the radiographs according to the Lauge-
Hansen classification [4]. The supination-external rotation (SER)
fracture was defined as a malleolar fracture with an oblique fibular
fracture starting at the level of syndesmosis (Fig. 1). In pronation-
external rotation (PER) fractures, the fibular fracture started
proximal to the syndesmosis (Fig. 2). In pronation-abduction (PAB)
fractures a multifragmentary, indirect fibular fracture was
observed (Fig. 3). A completely infrasyndesmotic fibular fracture
sometimes accompanied by an almost vertical medial malleolar
fracture was considered characteristic for a supination adduction
(SAD) fracture (Fig. 4). The stages of each fracture mechanisms
were analyzed. Fractures were deemed to be low-stage injuries if
they represented SER I–II, PER I–II, PAB I–II or SAD I. Fractures were
deemed to be high-stage injuries if they represented SER stage III–
IV, PER stage III–IV, PAB stage III or SAD stage II.
All discrepancies between the investigators were identified.
These sets of X-rays were jointly reassessed by both investigators
and the specific features characterizing each fracture type were
discussed in an attempt to reach consensus. When assessing the X-
rays, the investigators were blinded to the patients’ response with
respect to the fracture mechanism.
Fig. 1. Example of SER-type fracture X-ray — (a) mortise and (b) lateral. This patient
3. Results
sustained fracture while biking, in pronatory mechanism (toes striking the obstacle
3.1. Study population with the foot on the pedal).

In total 110 (55 women and 55 men with an average age of
47.8 years) patients with acute malleolar fractures were screened
for this study. Of those 32 patients did not meet the inclusion
criteria thus leaving a group of 78 patients for analysis. The study
group consisted of 43 women and 35 men with a mean age of 47.8
(range 19.5–88.4) years. The reasons for exclusion were: high
energy fracture in 10, inability to recall the fracture circumstances
in 28, and intoxication at the time of injury in 7 (multiple reasons
were possible).
3.2. Patient reported mechanisms
The majority (35/78 = 44.8%) of patients reported pronation
as their fracture mechanism, 27 (34.6%) patients reported
96 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100
Fig. 2. Example of PER-type fracture X-ray — (a) mortise and (b) lateral. The patient
reported supination-hyperplantarflexion mechanism.
supination, 15 (19.2%) patients reported hyperplantarflexion
(three patients reported pure hyperplantarflexion, one combined
with pronation and 11 combined with supination), and 1 patient
reported hyperdorsiflexion combined with pronation. The hyper-
plantarflexion and hyperdorsiflexion mechanisms have been
added to the protocol as they were spontaneously reported
by the patients. The underlying mechanisms of injury reported by
Fig. 3. Example of PAB-type fracture X-ray — (a) mortise and (b) lateral. This patient
could not recall the fracture mechanism and was excluded from analysis.
the patients were slipping on uneven ground (49%), falling
down a flight of stairs (22%), biking (4%), football (4%), other
sports (8%) and less frequent accidents like dancing, fall
from height under 2 m, fall with a motorcycle, fall from
chair, fall into the ditch, and being hit by a car in or near a
parking lot or car park at a speed of less than 20 kilometers per
hour (13%).
 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100
Fig. 4. Example of SAD-type fracture X-ray — (a) mortise and (b) lateral. This patient
reported supinatory mechanism after falling into the ditch.
3.3. Assessment of X-rays
The X-rays were assessed by two independent investigators.
Inter-observer agreement was achieved in 87% of cases. The 14 sets
of X-rays with discrepancies were reassessed jointly and discussed.
An agreement could be reached in 13 cases, with 7 cases finally
classified in concordance with investigator 1 opinion and
6 according to investigator 2 opinion. This left one case that was
impossible to classify. This case was excluded from further
analysis.
97
Table 1
Correlation between mechanism of fracture reported by the patient and X-ray
classification.
Patient reported mechanism X-ray classification
Pronation 34x 5x PER
1x PAB
28x SER
Supination 27x 20x SER
6x PER
1x SAD
Hyperplantarflexion Pure 3x 3x SER
With pronation 1x 1x SER
With supination 11x 9x SER
2x PER
Hyperdorsiflexion 1x 1x PER
Total number of reported fracture mechanisms: 77 35x (45%) concordance
with radiographs
Concordant radiographs are presented in bold.
The analysis of X-rays revealed 61 SER (79%), 1 SAD (1.3%),
14 PER (18%), and 1 PAB-type (1.3%) fractures according to the
Lauge-Hansen classification. Among patients who could not recall
the mechanism there were 13 SER (46%), 2 SAD (7%), 10 PER (36%)
and 3 PAB (11%) fractures.
3.4. Correlation of patient reported mechanism and X-ray
classification
The information on the correlation between mechanism of
fracture reported by the patients and the X-ray classification by the
surgeon is summarized in Table 1. The patient reported mecha-
nisms were in concordance with the mechanism deducted from
the X-rays in 45.5% of cases.
Of 35 patients that reported a pronation mechanism, including
one in combination with hyperplantarflexion, only 6 (17.1%) had
fracture radiographs classified as pronation type injuries. Of
38 patients that reported a supination mechanism, including 11 in
combination with hyperplantarflexion, 29 (76.3%) had fracture
radiographs classified as supination type injuries. Of 15 patients
that reported a hyperplantarflexion mechanism, 13 were radio-
graphically classified as having supination type injuries. The one
patient who reported a hyperdorsiflexion injury was radiograph-
ically classified as having a pronation type injury.
It may be argued, however, that hyperplantarflexion and
hyperdorsiflexion do not constitute the Lauge-Hansen mecha-
nisms’ of fracture. If only patients reporting supination or
pronation mechanisms were analyzed, the concordance between
X-rays and patient reported injury mechanism dropped to 42%.
3.5. X-ray ability to predict the reported fracture mechanism
Correlation between X-ray classification and patient reported
mechanism of fracture is summarized in Table 2. In 48.1% of cases
the X-ray classification was able to predict the fracture mechanism
as reported by the patient. This number dropped slightly to 44%
after excluding patients with hyperplantarflexion/hyperdorsiflex-
ion mechanisms.
Among the 15 patients that were classified to have pronation
type injuries, only 7 (46.7%) actually reported to have suffered a
pronation trauma. Among the 62 patients that were classified to
have supination type injuries, only 30 (48.4%) actually reported to
have suffered a supination trauma.
98 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100
Table 2
Correlation between X-ray classification and patient reported mechanism of fracture.
X-ray Lauge-Hansen classification
PAB 1x
PER 14x
SAD 1x
SER 61x
Total number of classified radiographs: 77
Concordant radiographs are presented in bold.
Table 3
Correlation between X-ray classification and patient reported mechanism of fracture for the low-stage subgroup.
X-ray Lauge-Hansen classification
PER 3x
SER 16x
Total number of classified radiographs: 19
Concordant radiographs are presented in bold.
3.6. Low-stage subgroup
There were 19 patients that presented with a low-stage
fracture. Correlation between X-ray classification and patient
reported mechanism of fracture in this group is summarized in
Table 3. Similarly to the whole study population, 11 of 16 patients
(68.8%) with a SER X-ray type reported supination as fracture
mechanism, while only 1 of 3 patients (33.3%) with a PER X-ray
reported pronation as fracture mechanism.
4. Discussion
The genetic Lauge-Hansen classification links the morphology
of malleolar fractures with the deforming forces acting on the
ankle joint. In his original experiments, Lauge-Hansen manually
put the foot in either pronation or supination and exerted an
additional external rotation, abduction or abduction force resulting
in four classical fracture patterns: supination-external rotation
(SER), pronation-external rotation (PER), supination-adduction
(SAD) and pronation-abduction (PAB). This classification led to the
development of appropriate closed reduction techniques. Nowa-
days, with wider use of open reduction and internal fixation,
genetic reduction maneuvers proposed by Lauge-Hansen are less
important to orthopedic surgeons. Nevertheless, the ability to
deduct the mechanism of fracture from the radiographic fracture
morphology is of great importance in forensic medicine. The
morphology of the malleolar fracture is used to reconstruct
possible circumstances of injury [1,2].
In the present study we found a less than 50% concordance
between patient-reported mechanisms of ankle fracture and the
corresponding X-ray images when analyzed in a blinded manner.
The results strongly suggest that the type of ankle fracture is not as
Patient reported mechanism of fracture
1x pronation
5x pronation
1x pronation + hyperdorsiflexion
6x supination
2x supination + hyperplantarflexion
1x supination
20x supination
9x supination + hyperplantarflexion
28x pronation
1x pronation + hyperplantarflexion
3x hyperplantarflexion
37x (48%) concordance with reported fracture mechanisms
Patient reported mechanism of fracture
1x pronation + hyperdorsiflexion
2x supination
8x supination
3x supination + hyperplantarflexion
4x pronation
1x hyperplantarflexion
12x (63%) concordance with reported fracture mechanisms
closely related to the fracture mechanism as postulated by the
Lauge-Hansen classification. We observed an 87% interobserver
reliability and were unable to classify just one fracture (1.3%) with
the Lauge-Hansen classification system. While Lauge-Hansen
himself has admitted that 5% of the fractures in his series were
not compatible with his classification system [4], a more recent
study employing MRI has found that 10 of 59 fractures (17%) could
not be classified and that in the remainder the ligamentous injuries
were not compatible with the injury stages as predicted by this
classification in 53% [12]. Several authors have reported a low to
moderate reproducibility of the Lauge-Hansen classification
[9,10,13].
Warner et al. showed, using preoperative MRI and intra-
operative findings, that the Lauge-Hansen system is an accurate
predicator of ligamentous injuries [14]. Of their 283 fractures that
were classified, 94% of them (266 patients) had ligamentous
injuries consistent with the Lauge-Hansen predictions. While the
existence of four distinctive radiographic fracture types as
postulated by Lauge-Hansen is unquestioned, the interpretation
of mechanism leading to these fractures is controversial. Several
authors have failed to reproduce the results of the original Lauge-
Hansen experiments in a standardized setting [6,8].
When analyzing our results in detail, only 17% of patients who
recalled a pronation trauma actually had radiographs classified as
pronation fractures while 76% of patients who recalled a
supination trauma also were radiographically classified as having
sustained supination type fractures. This indicates, that a
substantial portion of fractures classified radiographically as SER
may be in fact have been produced by a pronation mechanism. This
is in accordance with a cadaveric study by Haraguchi et al., where
researches were able to obtain fractures with SER type X-rays by
application of various pronatory forces [15].
 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100
In a recent study, Rodriguez et al. were able to compare the
fracture mechanisms seen in the YouTube video material of the
injury with the fracture radiographs [7]. They observed a 65%
concordance between the fracture mechanism and fracture type
according to the Lauge-Hansen classification which is slightly
higher than in our study but still at least a moderate correlation.
Due to the inherent selection bias of the YouTube video material,
their group of 30 patients included 20 skateboarders aged 13–
24 years. Because of this very specific group of patients, Rodriguez
et al. did not identify any fracture video representing a SER
mechanism [7]. We believe that our group more closely resembles
the average patient population sustaining rotational ankle
fractures with both pronation and supination of the foot at the
time of fracture being reported. Still, some our findings are
comparable to those of Rodriguez et al. as both studies concluded
that substantial percentage of fractures appearing radiographically
as SER injuries had been actually produced by a pronation fracture
mechanism.
Interestingly, 11 of 38 (29%) patients reporting supination did so
in combination with hyperplantarflexion. This mechanism was
most commonly reported as slipping down stairs with the knee
extended. In 30% of these patients we observed fractures of the
posterior tibial rim that are not completely explained by the Lauge-
Hansen classification and may represent a transition to posterior
pilon fractures [16–18]. From a biomechanical standpoint, it seems
logical that supination of the foot is combined with plantarflexion
during the three-dimensional movement of the ankle, subtalar and
mid-tarsal joints in an open kinetic chain as stated in the classical
anatomic texts [19,20]. On the other hand, pronation is combined
with dorsiflexion as reflected by the one patient in our study who
reported a hyperdorsiflexion injury and had radiographs classified
as a pronation type injury.
Our study has important medicolegal implications. We
observed a poor correlation between the fracture mechanism
postulated by Lauge-Hansen classification and the fracture
mechanism reported by the patients. Consequently, the fracture
mechanism as postulated by the Lauge-Hansen classification
should not be the only source of information for medicolegal
reasoning as supination and pronation type fractures can be
produced by variety of forces. It appears that the Lauge-Hansen
system is not a reliable tool for accident research. In light of the
results of the presented study we suggest that analysis of injury
patterns and radiographic findings alone may not provide
sufficient information to deduce the mechanism of injury.
Therefore, additional information such as soft tissue injury (above
all contusion marks, the shape and any visible contamination of
open wounds), a thorough description of all accompanying
circumstances of the accident, evidence collected at the scene of
accident, or vehicle crash reconstruction information should also
be analyzed if available.
The results from our study are in concordance with an earlier
study by Madeley et al. using experimentally created injuries [21].
The authors found that orthopedic specialists could not consis-
tently deduce the primary mechanism of ankle injuries in
experimentally generated malleolar fractures and that the
Lauge-Hansen classification does not reliably describe ankle
fractures created in an impact environment [21]. The usefulness
of foot and ankle injury classifications was also verified in
biomechanical studies regarding the safety of car occupants with
respect to crash location (frontal vs. oblique) and sitting position
(driver vs. front seat passenger). However, these studies did not
focus on the mechanism of injury itself, but mainly on its extent
and severity [22].
The conclusions of our study may influence medicolegal
reasoning in the cases where ankle fractures are observed. This
includes victims of low energy motor vehicle accidents (e.g. at
99
parking lots, pedestrian crossings), direct injuries in car parks, but
also tangent hits of pedestrians moving in the same direction by a
mirror or side of the car. The circumstances of the incident areoften
obscured by divergent circumstances provided by the victim and
the alleged perpetrator. Conflicting evidence may be given for the
position of a pedestrian in relation to the vehicle (blunt trauma
from lateral, medial, front or back side of the leg) as well as
existence or lack of direct contact between the leg and the vehicle
(hitting with the bumper versus fracture or resulting from loading
improperly positioned foot). From a medicolegal point of view the
ability to explain mechanism and circumstances of the injury is
crucial in terms of determining legal responsibility for the
incident. As these types of injuries are usually non life-
threatening, the only objective medical data to analyze the
fracture mechanism are the medical history, the clinical findings
and radiographic images of a patient. Apart from the direction of
forces as covered by the Lauge-Hansen classification, for
medicolegal purposes one has to further differentiate between
active and passive injuries, accidental and intentional injuries,
and falls from the erect position vs. throwing somebody off
balance (e.g. the direction of pushing).
Our study has also important shortcomings. First, it was
dependent on the ability of the patients to recall the circumstances
leading to the fracture. 70% of the patients in our group felt
confident enough to do this. We believe this high percentage was
due to exclusion of patients with high energy injuries making
proper recall of the fracture mechanism and position of the foot at
the time of injury difficult. Our results are probably not applicable
to high-energy fractures where multiple injuries exist that may be
life-threatening. In such injuries, the rotational component is
negligible. A detailed analysis of such injuries was provided in
previous studies [1,2].
Another potential weakness is uncertainty about the patients’
faithfulness. The question of patient sincerity is an important issue
in medicolegal reasoning. Patients may give false information,
fearing the legal consequences of honesty or loss of financial
compensation [23–25]. We admit that optimal material would be
video recording of the fracture mechanism, however, this will not
be available for most of the cases. In our study patients were
questioned by a surgeon from the team providing the treatment.
We believe this situation gave the patients no incentives to be
dishonest. It may even be argued that our patients strived to
provide the treating team with as correct information as possible in
order to support the surgical treatment. It may even be argued that
patients were incentivized to provide fracture circumstances even
if they were not confident about them. We believe this does not
apply to our data for two reasons. First, the patients were
questioned in non-challenging environment and 30% admitted not
remembering the circumstances. Second, in the preparation for
this study we performed a preliminary study on twenty patients
with a lateral ankle sprain. These patients all gave description of a
supination trauma, which is consistent with our understanding of
the sprain mechanism. We therefore assume that we received
reliable information from the patients.
To improve reliability of the responses only the information on
pronation and supination, without the information on rotatory
forces, was collected. This complicates the analysis as the fractures
occur as a result of combination of forces and the number of
fractures without rotatory component (PAB and SAD) were too
small for sound analysis. We tried to compensate for this
shortcoming with analysis of low-grade subgroup of fractures,
where rotational forces should be less important. The results were
following the general pattern, but indeed, the performance of the
Lauge-Hansen classification was slightly better.
For methodological reasons, we only included patients requir-
ing surgical treatment. While this may be perceived as introducing
100 A. Boszczyk et al. / Forensic Science International 282 (2018) 94–100
a certain selection bias, these patients are the ones who most likely
receive medicolegal attention.
5. Conclusion
In summary, when comparing the patient reported injury
mechanism with the radiologic fracture mechanism, the Lauge-
Hansen classification was able to predict the fracture mechanism
in less than 50% of cases. Of patients who reported pronatory
mechanism only 17% presented X-ray compatible with pronation.
We conclude that a substantial portion of SER type fractures may
actually have been produced by a pronation force. These
observations, together with recent biomechanical, radiographic
and clinical studies, question the use of the Lauge-Hansen
classification as the only source of findings for medicolegal
reasoning. Analysis of injury patterns and radiographic findings
alone may not provide sufficient information to deduct the
mechanism of injury. Additional information such as soft tissue
status, accompanying injuries, circumstances of the accident,
evidence collected at the scene of accident, and other information
available should be analyzed and considered. In addition,
radiological documentation should be analyzed by highly experi-
enced orthopedic surgeons or radiologists.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
SR received non-financial support in the form of Travel/Housing
for AO Meetings, Courses as Member of the Foot & Ankle Expert
Group.
Other authors declare that they have no conflict of interest.
This is non-interventional retrospective study. For this type of
study formal consent is not required.
Informed verbal consent was obtained from all individual
participants included in the study.
References
 ski, R. Madro, Evidential value of injuries useful for reconstruction of
[1] G. Teresin
the pedestrian-vehicle location at the moment of collision, Forensic Sci. Int.
128 (2002) 127–135.
 ski, R. Madro, Ankle joint injuries as a reconstruction parameter in
[2] G. Teresin
car-to-pedestrian accidents, Forensic Sci. Int. 118 (2001) 65–73.
[3] S. Schmidt, R. Schulz, H. Pfeiffer, A. Schmeling, G. Geserick, On the evidential
value of a Messerer fracture sustained in a car-pedestrian traffic accident, Int. J.
Legal Med. 130 (2016) 1593–1597, doi:http://dx.doi.org/10.1007/s00414-016-
1437-x.
[4] N. Lauge-Hansen, Fractures of the ankle. II. Combined experimental-surgical
and experimental-roentgenologic investigations, Arch. Surg. 60 (1950) 957–
985.
[5] J.O. Nielsen, H. Dons-Jensen, H.T. Sørensen, Lauge-Hansen classification of
malleolar fractures. An assessment of the reproducibility in 118 cases, Acta
Orthop. Scand. 61 (1990) 385–387, doi:http://dx.doi.org/10.3109/
17453679008993545.
[6] J.Y. Kwon, I.L. Gitajn, P. Walton, T.J. Miller, P. Appleton, E.K. Rodriguez, A cadaver
study revisiting the original methodology of Lauge-Hansen and a commentary
on modern usage, J. Bone Joint Surg. Am. 97 (2015) 604–609, doi:http://dx.doi.
org/10.2106/JBJS.N.00970.
[7] E.K. Rodriguez, J.Y. Kwon, L.M. Herder, P.T. Appleton, Correlation of AO and
Lauge-Hansen classification systems for ankle fractures to the mechanism of
injury, Foot Ankle Int. 34 (2013) 1516–1520, doi:http://dx.doi.org/10.1177/
1071100713491730.
[8] J. Michelson, D. Solocoff, B. Waldman, K. Kendell, U. Ahn, Ankle fractures. The
Lauge-Hansen classification revisited, Clin. Orthop. Relat. Res. (1997) 198–205.
[9] M.-C. Yin, X.-F. Yuan, J.-M. Ma, Y. Xia, T. Wang, X.-L. Xu, Y.-J. Yan, J.-H. Xu, J. Ye,
Z.-Y. Tong, Y.-Q. Feng, H.-B. Wang, X.-Q. Wu, W. Mo, Evaluating the reliability
and reproducibility of the AO and Lauge-Hansen classification systems for
ankle injuries, Orthopedics 38 (2015) e626–e630, doi:http://dx.doi.org/
10.3928/01477447-20150701-62.
[10] S.S. Shariff, D.K. Nathwani, Lauge-Hansen classification—a literature review,
Injury 37 (2006) 888––890, doi:http://dx.doi.org/10.1016/j.injury.2006.05.013.
[11] J.L. Marsh, T.F. Slongo, J. Agel, J.S. Broderick, W. Creevey, T.A. DeCoster, L.
Prokuski, M.S. Sirkin, B. Ziran, B. Henley, L. Audigé, Fracture and dislocation
classification compendium — 2007: Orthopaedic Trauma Association classifi-
cation, database and outcomes committee, J. Orthop. Trauma 21 (2007) S1–
S133.
[12] M.J. Gardner, D. Demetrakopoulos, S.M. Briggs, D.L. Helfet, D.G. Lorich, The
ability of the Lauge-Hansen classification to predict ligament injury and
mechanism in ankle fractures: an MRI study, J. Orthop. Trauma 20 (2006) 267–
272.
[13] S.M. Verhage, S.J. Rhemrev, S.B. Keizer, H.M.E. Quarles van Ufford, J.M.
Hoogendoorn, Interobserver variation in classification of malleolar fractures,
Skeletal Radiol. 44 (2015) 1435–1439, doi:http://dx.doi.org/10.1007/s00256-
015-2179-4.
[14] S.J. Warner, M.R. Garner, R.M. Hinds, D.L. Helfet, D.G. Lorich, Correlation
between the Lauge-Hansen classification and ligament injuries in ankle
fractures, J. Orthop. Trauma 29 (2015) 574–578, doi:http://dx.doi.org/10.1097/
BOT.0000000000000393.
[15] N. Haraguchi, R.S. Armiger, A new interpretation of the mechanism of ankle
fracture, J. Bone Joint Surg. Am. 91 (2009) 821–829, doi:http://dx.doi.org/
10.2106/JBJS.G.01288.
[16] N. Haraguchi, H. Haruyama, H. Toga, F. Kato, Pathoanatomy of posterior
malleolar fractures of the ankle, J. Bone Joint Surg. Am. 88 (2006) 1085–1092,
doi:http://dx.doi.org/10.2106/JBJS.E.00856.
[17] J. Bartoní9
cek, S. Rammelt, K. Kostlivý, V. Vane c9ek, D. Klika, I. Trešl, Anatomy and
classification of the posterior tibial fragment in ankle fractures, Arch. Orthop.
Trauma Surg. 135 (2015) 505–516, doi:http://dx.doi.org/10.1007/s00402-015-
2171-4.
[18] G. Klammer, A.R. Kadakia, D.A. Joos, J.D. Seybold, N. Espinosa, Posterior pilon
fractures: a retrospective case series and proposed classification system,
FootAnkle Int. 34 (2013) 189–199, doi:http://dx.doi.org/10.1177/
1071100712469334.
[19] V. Inman, The Joints of the Ankle, Williams & Wilkins, Baltimore, 1976.
[20] R. Fick, Handbuch der Anatomie und Mechanik der Gelenke unter
Berücksichtigung der bewegenden Muskeln. Teil I, Gustav Fischer Verlag,
Jena, 1904.
[21] N.J. Madeley, C.M.S. Srinivasan, J.R. Crandall, S. Hurwitz, J.R. Funk, Retrospec-
tive analysis of malleolar fractures in an impact environment, Annu. Proc.
Assoc. Adv. Automot. Med. 48 (2004) 235–248.
[22] C.S. Parenteau, D.C. Viano, P. Lövsund, C. Tingvall, Foot-ankle injuries:
influence of crash location, seating position and age, Accid. Anal. Prev. 28
(1996) 607–617.
[23] C.-C. Yang, K.-M. Yuen, S.-J. Huang, S.-H. Hsiao, Y.-H. Tsai, W.-C. Lin, Good-old-
days bias: a prospective follow-up study to examine the preinjury supernor-
mal status in patients with mild traumatic brain injury, J. Clin. Exp.
Neuropsychol. 36 (2014) 399–409, doi:http://dx.doi.org/10.1080/
13803395.2014.903899.
[24] N.D. Silverberg, G.L. Iverson, J.R. Brubacher, E. Holland, L.C. Hoshino, A. Aquino,
R.T. Lange, The nature and clinical significance of preinjury recall bias
following mild traumatic brain injury, J. Head Trauma Rehabil. 31 (6) (2016)
388–396, doi:http://dx.doi.org/10.1097/HTR.0000000000000198.
[25] V.Y. de Moraes, K. Godin, J.B.G. Dos Santos, F. Faloppa, M. Bhandari, J.C. Belloti,
Influence of compensation status on time off work after carpal tunnel release
and rotator cuff surgery: a meta-analysis, Patient Saf. Surg. 7 (2013) 1, doi:
http://dx.doi.org/10.1186/1754-9493-7-1.